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Neighborhood Gouncil Funding
Et**p6r4'ERux-ffi
Program
i'a';x;l;looD
purposes Grant (NPG)
AppLrGATroN for Neighborhood
seekins'n"
rhis form is to be compreted bv the appricant
€MPovrrRr*EHr
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:.l[+H:"S:Empowerment
Neighborhood
oi
ap
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i
Palms Neighborhood Council
NaqeofNeighborhoodCounci|yoUareseekingthegrantrom:
Motor Avenue Foundation
t\lbrganization Name
37 51 Motor Avenue #341248
1B)
ffi;
City
City
Adiress (tf different)
cable)
1D)
::
State of lncorPorauon
Los Angeles
Mailing Address
@mon
1C)
ffiiTD#(EtN#)
0912012
CA
45-5405527
CitY
CA
:
Date
of 501(c)(3)
Status (if aPPlicable)
90034
State
Zip Code
State
Zip Code
Sfafe
Zip Code
Name:
Nameandaddressofpersondesignatedtoreceiveofficial/legalnotices:
City
Streef
anilatio1frx;i|,"rfi"f.:?
of o1oln!zat13n::,:i,::"^:,:.::1"::"j.fo'n trr
3) rv*,
'ffi
schools)
'- vv r\Y/\-/
punti" S"hool (notto
Attach Letterhead
inctudeprivate
ffi-affi
Angetes)
i"wii,:::,:::!'':f"k?;
Attach IRS Determination Letter
4)PleasedescribetheNeighborhood|mprov6mentProjectforwhichthegrantisintended.
rhis runding
wirr provide
Recvcrins
marketip,'uryl?:^t"^i::P.?::T[: il1ffi:lJl:]::ilftYXTe
:!",J!Xi#ff ;J"ffirK;;;;rmpiou"mentAssociationand
already spent $450
I5r3li';Xilil['il:iff
Arro"iution unJ-coripuTech have
Motor Avenue rmprovemJnt
and make sure Palms
compuTech.
in!
to
oroeri;;;;ti;;"
tn
"orrunitv
Associate would like to double
"ouJrt"
dorars on outreach materiars.
Avenu"-ri,p,.oultent
r'rotor
prop"irv,
residents dispose of the ewaste
in" tutr."ting efforts already underway'
5)
pub'c purpose and benefit the
a non-discriminatory,
serve
or
support
to primarily
How wilr this grant be used
Public at-large'
such as
TheLoca|E|ectronicWasteRecyc|ingprogram|,?l'i'portantserviceforthePa|mscommunity.
of the harmfur heavy metars
o"*ui"
necessarv
is.,incrJoiory
are not
Disposing of ewaste properry
in electronics. rf electronics
i"und
in"i"i"
potentia*y;;;,.n"t"riur,
u public
red and copper ano oinei
1"".n inio soit and ground*?l9t
nururolul r"t"riur. "un
a.n accessible
providing"?:tllg
disposed ot properry, these
etrorts on this matter lnd
marketing
ensure all Palms residents
hearth risk. By continued
n.ro.iation"'r,ipl.ioltr""tiu"ly
rrproirJrl,it
disposar site, Motor Avenue
'
responsibly
waste
of electronic
;il';;;;itn
li;;;."
City of Los Angeles, Department of Neighborhood Empowerment
NPG APPLICATION Paqe 2
fotal Proiected:,Cost
Requested of NC
6A) Personnel Related Expenses
I
N/A
Total Proiected Cost
Requested of NC
6B) Non-Personnel Related Expenses
$
Flyers
Racks
3o.oo o
$
350.00
70.00
Rack Cards
s
D
7l ls the implementation of this specific program or purpose described in box 4 above contingent on any other
factors or sources or funding? D Yes, please describe below tr No
Total Proiected Cost
Amount
Source of Fundinq
t
D
8)
What is the TOTAL amount of the grant funding requested with this application:
s)
What is the expected completion date?
3 1 1 1 2015 (mm/dd/yyyy)
$ 450.00
(required)
@onenumber,faxande-mai|address(ifapp|icab|e)oftheperson(s)responsiblefor
the funds and program(s) listed in Section ll of this application.
Wallach
Lee
(310)202-e002
Telephone Number
(31)202-0433
Polizzotto
108\ First Name
Last Name
Telephone Number
[email protected]
E-mail
Fax Number
Nikki
(310)202-9002
MI
Last Name
10A) Fr'rsf Name
MI
(310)202-0433
Fax Number
11) ls there a former or existing relationship between your organization and a NG board member?
11A)lf yes,didyouand/ortheboardmemberconsulttheOfficeof theCityAttorney? [ Yes ENo
lvpe of RelationshiP
Board Member Name
Example: Former board member
So Conflicted
City of Los Angeles, Deparlment of Neighborhood
Empowerment
NPG APPLICATIoN Page 3
I hereby affirm that, to tne
o?Effiil,"dn
:H'"f,[1,"#;?:::lJi1T1;,1']Ij::-:11:TT1l.lTj;
"conflicts of Interest" of this
Gst
e, "what is a p"i,i" Benerit,', and Appendix B
application and affirm that the
^;;;noi'
proposed project(s)
criteria of a pubtic benefit project/program and
that no conflict of interest exist that would prevent
the awarding of
Two signatures required
""oror";:;;"*iJ[,iii"rT';:
.,1
12A) Executive Director of Non-profit Gorporation
or Schoor principal
Lee Wallach
Executive Director
PRINT First Name/ Last Name
Title
128) Secretary of Non-profit corporation
or Assistant school principal
Nikki Polizzotto
Receivecl
-
Date Reviewed
lDate submirca to
f
ue+eei
runffiGii
-..tr- lr.g.r9gl. - -? -Er."]!..
t!
,1n1,.
Signatu're
",
Date .
Signature
Date
Project Manager
PRINT First Name/ Last Name
iDate
./
':''
-B-
fgl.
_?- !t".,:ggpe$ne_!la.l
me,.J
;1..,rr
'it
{
INTERNAI REI/ENUE SERVTCE
P. o.
CINCINNATI,
Dare:
DErirRt{lfBlrf
BOx 2508
olt
or
irnE txr{l,stiny
45,201
nm1l_oVe1
stP 27 mn
fdent,if ication Nunber
45-5405'527
:
DhN:
:.to3ilA*iaitOt;z
Contai:t person:
MoroR aVeNUs rourvoerrpu
3751 MoTOR Ar/a gTE 341248
rros ANGErrEs, cA 9ooi4
GERRY R tylCLAUcI{fJIN
Contact Tb.Lerllhone Number
(877) 82e_5s00
Accoungtng period lrtding
3l
public Charity Status:
December
*
(bt (1i(ifi"(vii
Form 990 Requlred:
1?o
rD# 3L11s
:
:
.
yes
Effect,ive Date of bcem;rtion:
March !2, ZOLT
Contrlbut,ion Deduct{bllity :
Yea
Addendun
Applies:
No
Dear Applicant:
are plea€ed to Lnform you that, upon revlew of your
exempt Bt'atua we have det'ermLned thac you are exenpt appricat,ron for tax
under sectLon 501(c)(3) of the rnternal nevenue coie.from Federal incgme taN
Eo you are
deductlbLe under seetion 1?0 of the code. you are alaocontribubiona
guarified
to
reeeiv€
tax deductible beg'ests, devJ.see, traneferE or gifts oic"" eection
20ss, 2105
or 2522 of the code, Becauee this letter coul"d
hetrp resolve any questJ.ona
regarding your exempt status, you should keep it ln'your perman€nt
recorde.
hle
org:nl2aglonE exempt under sectiofl So1(c)(3) of the Code
as either pr.rbLic charltie'b or private foundations. tfe are furth€r classified
clet.enndned, that you are
a public charity. r.rnder the Csde eee.U&-ow(s, Lj*p,Ued *rn-,Sb-{Fr
hFaal$ng .o.f
leEter.
-
PLeaae eee encr.osed
charitieF, for some
exempt organizatlon.
kh,{E
pr:blication 42zr-pc, compltance cuide for sor,(e) (l)
herpful inforrnation aboui your resfonsibtrLt,iee aa anFublic
Lette.r 947
(DO/cc)
ry
/
T,IOTOR
AVENUE FOUNDAT
ON
gincerely,
Director,
Exempt- OrganizaLions
Rul-ings and Agreements
Enclosure; publicatio:n
4221-pC
Lett:er
947
(DO,/CG)
,.,,' lllf-9
Request for Taxpayer
ldentification Number and Certification
(Hov. August 2013)
Department of the T{easury
lnternal Revenue Service
Give Form to the
requester. Do not
send to the lRS.
Name (as shown on your incoms tax return)
Motor Avenue Foundation
c!
Business name/disregardod entity name, if
O
Motor Avenue
.G
c
",2
ab
t'x
oi
FZ
o- .t
E
oq)
Association
I
Exemptions {see instructions):
Check appropriate box.lor federal tax classlfioation:
I
proprietor E]
tndividuat/sote
c Coriroratlon
n
s
corporation fl
Partnership
n
Trust/ostate
Exempt
I
LimiteO liability company. Enter the tax classification (C=C corporaiion, S=S corporation, P=padnership)
!
Otner lsee instructions) >
>
pays
code (jl any)
Exemption from FATCA reporting
code (if any)
Requsster's name and address (optional)
Address (number, str€61, anil apt- or suite no.)
3751 Motor Ave #341248
City, state, and ZIP code
c)
a Los An{eles. CA 90034
LIst account number(s) here (optional)
ldentification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions.on page 3. For other
entities, it is your employer identification number (ElN). lf you do not have a number, see How to get a
I/N on page 3.
Note. lf the account is in moro than one name, see the chart on page 4 for guidelines on whose
number to enter.
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.
I am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notilied by the Internal Revenue
Service (lRS) thai I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3.
I am a U.S. citizen or
other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicatino that I am exempt from FATCA repofting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently sub.iect to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For modgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (lRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TlN. See the
instructions on oaoe 3.
Sign
Here
s.ignatureof
)
General Instrubtions
U.S. person
///5
...4' 7/
'z
tt*l
withholding tax on foreign partners' share of etfectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicaling that you are
exempt from the FATCA reporting, is correct.
Section references are to the lnternal Revenue Code unless otherwise noted
Future developments. Ths IBS has created a page on lRs.gov for intormation
about Form W-9, al www.irs.gavlw9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we r€loase it) will be posted
on that page.
Note. lt you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TlN, you must use the requester's form if it is substantially
similar to this Form W-9.
Purpose of Form
person if you ara:
A person who is required to file an information return wilh th€ IRS must obtain your
correct tilpayet identification number OIN) to report, for example, income pald to
you. payments made to you in settlement of payment card and third party network
transactions, real estate transactions, moftgage interest you paid, acquisition or
abandonment of secured propedy, cancellation of debt, or contributions you mada
to an IRAUse Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN to the person requesting it (the requester) and, wnen
applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting tor a number
to be issued),
2. Certity that you are not subi€ct to backup withholding, or
3. Claim exemption from backup withholding if you are a U.s. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S- trade or business is not subiect lo the
Delinition of d U.S. person. For federal tax purposes, you are considered a U.S.
.
An individual who is a U.S. citizen or U.S. resident alien,
A partnership, corporation, company, or association created er organized in the
United States or under the laws of the Unitod States,
.
.
.
An sstate (other than a loreign estate), or
A domestic trust (as defined in Regulations saction 301 .7701 -7)"
Special rules for partnerships. Partnerships lhat conduct a trade or business in
the United States ars generally roquired to pay a withholding tax under section
1446 on any foreign partner6' sharo of etfectiv€ly connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been recaived,
the rules under section 1 446 require a partnership to presume that a partner is a
foreign person, and pay the section 1 446 withholding tax. Therefore, ii you are a
U-S- person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.
Cat. No. 10231X
Form
W-9
Hev.8-2013)